MEDICARE: QUEENNIE GAN RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	17771	NV

General Provider Information

NPI Number	:	1144679515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QUEENNIE GAN RPH

Provider Business Mailing Address
First Line	:	PO BOX 91852
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89009-1852
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 N NELLIS BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-5321
Country	:	US
Telephone Number	:	702-452-8118
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2016
Last Update Date	:	06/07/2016

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Directions to “ QUEENNIE GAN RPH” Practice Location

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